The Female Athlete Triad

The Female Athlete Triad is and should be a concern for coaches and sports parents — as well as for young women who play sports. The triad is a grouping of three interrelated health conditions sometimes found in female athletes. They are Menstrual Disturbances/Amenorrhea, Bone loss/Osteoperosis, and Energy Deficiency with our without disordered eating, “underfueling.” A survey of eighty high school athletes found that 78% of the respondents had one or more of these conditions. Given this high number and how the three conditions interact, the Female Athlete Triad is certainly something to be further examined.


Energy Deficiency

Disordered eating is often the cause of “underfueling.” In efforts to achieve or maintain a lower weight, women who diet run the risk of not consuming enough calories and nutrients to allow the body to run properly. On the other end, a deficiency can occur when an athlete overexercises and depletes their body’s energy storage too quickly or too frequently. The American College of Sports Medicine emphasizes the importance of resolving the issue of energy deficiency, as this component is the cornerstone of the Female Athlete Triad. Both menstrual disruption and bone loss are results of under fueling.

Aside from the significant health risks imposed by under fueling, young athletes are liable to reduce their ability to succeed on the field and in the classroom. Under fueling negatively impacts cognitive functions, can cause depression, and disallows the body from performing at its peak potential.

Menstrual Disturbances/Amenorrhea

As previously mentioned, energy deficiency can disrupt many bodily functions, including the productivity of various hormones. Some of the hormones directly affected by poor diet or overexercise regulate a woman’s fertility systems, such as GnRH (gonadotropin-rleasing hormone), LH (leteinising hormone), FSH (follicle stimulating hormone), prolactin, and progesterone. As a result, menstrual disturbances or a complete absence of menstruation (amenorrhea) may occur. This change in a young woman’s body is often the first obvious indicator that the Female Athlete Triad may be affecting her in other ways as well, which should promptly be investigated. Some research studies have indicated that it is the low body fat percentage which leads to amenorrhea, but emerging research suggests low body fat is simply a correlation — not a causation — of missed periods. As such, low body fat percentages should be taken as indicator that something more is happening.

The dangers of overlooking this body signal could potentially lead to later issues in fertility and child bearing, but no research studies have produced somewhat mixed results on this. Ultimately, this leads to a great concern, that is the loss of bone density.

Bone Loss/Osteoperosis

The third and final component of the Female Athlete Triad is bone loss, or osteoporosis. Estrogen is a hormone produced in the ovaries and plays an important part in ovulation and menstruation. However, it is also key in the body’s ability to absorb calcium in the intestines. The less estrogen a body produces, the more difficulty it has absorbing calcium, which is essential in maintaining bone health. Estrogen also plays a much more complex role in bone health. To understand its role, we must first understand the process of bone formation and bone remodeling.

Osteoblasts are bone cells which promote born formation. Osteoclasts are bone cells which break down bone and release minerals, in turn also transferring calcium into the blood stream, a process also known as bone resorption. These two types of bone cells work in tandem and delicate balance to create new bone and constantly remodel current bone cells. Estrogen moderates the functionality of both osteoblasts and osteoclasts. With osteoclasts (the cells that break down bones), estrogen inhibits their activity — keeping the bone resorption in check. Osteoblasts, the born-forming cells, are encouraged by the presence of estrogen.

So when estrogen is NOT present or only has a minimal presence, an imbalance of bone creation, bone remodeling, and bone resorption occurs.  The bones lose their density and become less able to support the skeletal structure and repair themselves after injury. Some studies have suggested that bone density loss as a result of amenorrhea can sometimes be irreversible, even with calcium supplements.


While it is important to note that any woman (athlete or not) is vulnerable to energy deficiency and the subsequent amenorrhea and bone loss, female athletes are at a greater risk due to pressures related to sports. Young women who participate in sports which require lean body mass, require weigh-ins to compete, or encourage a certain body shape are particularly susceptible to the disordered eating which can result in energy deficiency. Other external influences on these athletes could controlling parents and/or coaches, pressure to win “at all costs,” social isolation, consequences for gaining weight, etc. On top of these risk factors, it is alarming how many female athletes are told it is “normal” to have an absent menstruation cycle.

Many signs and symptoms, both behavioral and physical, can indicate an athlete may be affected by the Female Athlete Triad. From the NCAA Handbook on Managing the Female Athlete Triad: Signs and Symptoms of  Disordered Eating:


Behavioral Signs:

  • Anxiety or depression
  • Claims of “feeling fat” despite being thing
  • Excessive exercise
  • Excessive use of the restroom
  • Unfocused, difficulty concentrating
  • Preoccupation with weight and eating
  • Avoidance of eating and eating situations
  • Use of laxatives, diet pills, etc.


Physical/Medical Signs and Symptoms:

  • Amenorrhea
  • Dehydration
  • Gastrointestinal problems
  • Hypothermia (cold intolerance)
  • Stress fractures (and overuse injuries)
  • Significant weight loss
  • Muscle cramps, weakness, or fatigue
  • Dental and gum problems




iStock_000004700137MediumFirst and foremost in prevention of the Female Athlete Triad is awareness of the triad, its signs, and especially the short-term and long-term effects of disordered eating, amenorrhea, and osteoperosis. Coaches, parents, and especially athletes should be made aware of the risks. All groups should also become educated on how to recognize the triad. Other preventive measures can be taken as well. The Female Athlete Triad Coalition recommends the following prevention methods for coaches and athletes:



  • Remind your athletes that eating is an important part of successful training and performance.
  • Focus on health and a positive body image, do NOT focus on body weight.
  • Support athletes throughout their training and competition, as well as during their everyday life.
  • Mobilize available resources – nutritionists, athletic trainers, counselors, and physicians.



  • Monitor your menstrual cycle by using a diary or calendar
  • Consult your physician if you have mentsrual irregularities, have recurrent injuries or stress fractures
  • Seek counseling if you suspect you are overly concerned about your body image, for example, if you are constantly striving to be thin
  • Consult a sport nutritionist to help you design an appropriate diet that is specific to your sport and to your body’s energy needs.
  • Seek emotional support from parents, coaches and teammates.



The Female Athlete Triad represents a complex array of psychological and physiological issues which will need to be addressed. A team of support should be created, which can include: coaches, parents, athlete, mental health counselors, primary physicians, nutrition specialists, and, if necessary, medical specialists for bone loss and hormone therapy. Through the guidance of this team the athlete should strive to restore a healthy energy balance by maintaining a proper diet — this is often where much of the mental health counseling should focus. After consulting with a physician, the athlete can also begin strength and weight-bearing training, which can improve bone health.


Sports and athletics can greatly enhance a young woman’s well-being. This is where some parties take issue with the idea of the Female Athlete Triad. The concern is that some female athletes will shy away from sports, or that their parents’ concern of this danger will prohibit them from trying athletics. This is where education and awareness are key elements in fully understanding what the triad consists of and how it progresses. Along a similar vein, many supporters of female athletics feel that by implying these trio of health conditions is unique to females, it pathologizes being female. It is important to note that both men and non-athletes can also find themselves susceptible to the triad.


The Female Athlete Triad Coalition

Managing the Female Athlete Triad – PDF from NCAA

Materials for Coaches and Trainers from MedCo Sports Medicine